Portal Vein Stenting to Treat Portal Vein Stenosis in a Patient With Malignant Tumor and Gastrointestinal Bleeding

This report describes the successful use of portal venous stent placement for a patient with recurrent melena secondary to jejunal varices that developed after subtotal stomach preserved pancreatoduodenectomy (SSPPD). A 67-year-old man was admitted to our hospital with tarry stool and severe anemia at 2 years after SSPPD for carcinoma of the head of the pancreas. Abdominal computed tomography examination showed severe stenosis of the extrahepatic portal vein caused by local recurrence and showed an intensely enhanced jejunal wall at the choledochojejunostomy. Gastrointestinal bleeding scintigraphy also revealed active bleeding near the choledochojejunostomy. Based on these findings, jejunal varices resulting from portal vein stenosis were suspected as the cause of the melena. Portal vein stenting and balloon dilation was performed via the ileocecal vein after laparotomy. Coiling of the jejunal varices and sclerotherapy of the dilate postgastric vein with 5% ethanolamine oleate with iopamidol was performed. After portal stent placement, the patient was able to lead a normal life without gastrointestinal hemorrhage. However, he died 7 months later due to liver metastasis.Key words: Portal vein stenosis, Portal vein stent, PancreatoduodenectomyObstruction of the extrahepatic portal vein can lead to portal hypertension, splenomegaly, and gastrointestinal bleeding due to esophageal or gastric varices. Malignant portal vein stenosis accounts for 15 to 24% of all cases of portal venous stenosis or occlusion and usually results from portal vein tumor thrombus or external compression of the portal vein by neoplasms.^1–4 When a patient with malignant tumors undergoes subtotal stomach preserved pancreatoduodenectomy (SSPPD), formation of hepatopetal collaterals is precluded by lymph node dissection and resection of the peribiliary vascular plexus around the hepatoduodenal ligament. Instead, jejunal varices form at the choledochojejunostomy site. The treatment of portal vein stenosis remains controversial, and the indications for portal vein stent placement have not yet been clarified.This report describes a case of successful portal vein stenting for a patient with portal vein stenosis and repetitive bleeding from jejunal varices that developed after SSPPD.     

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: Report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.     

Unusual Bleeding From Hepaticojejunostomy Controlled by Adult Variable Stiffness Colonoscopy: Report of a Case and Literature Review

We herein present a case of a 59-year-old man who had undergone pylorus preserving pancreaticoduodenectomy with regional lymph node dissection prior to episodes of melena. Series of conventional endoscopic investigations failed to identify the bleeding source. Enhanced computed tomography scan revealed complete obstruction of the main portal vein with numerous collateral veins running towards the hepatic hilus. Comprehensively, hemorrhage from the jejunal varices caused by postoperative portal hypertension was highly suspected. As the jejunal loop was out of reach, adult variable-stiffness colonoscope (AVSC) was utilized to solve the Roux-en-Y anatomy. Numerous telangiectasis and small varices at hepaticojejunostomy were observed and in the mean time, bleeding was noticed and endoclips were placed without any delay. Ectopic variceal bleeding in jejunal loop after pancreaticoduodenectomy is difficult to manage. We believe that AVSC is an alternative device when specialized jejunal endoscopy is not available.Key words: Hepaticojejunostomy, Adult variable stiffness colonoscopy, Endoclip, Jejunal varicose vein, Portal hypertensionBleeding ectopic varices in the jejunal loop after biliary reconstruction is a rare entity.¹ Management of such bleeding is difficult and is not well defined. Here, we report a case of a pancreatic cancer patient who had pylorus-preserving pancreaticoduodenectomy (PD) 2.5 years prior to variceal bleeding at hepaticojejunostomy (HJ) anastomosis (Roux-en-Y fashion). We successfully treated this out-of-reach afferent jejunal loop bleeding by using adult variable stiffness colonoscopy (AVSC).     

An elusive cause of haemoperitoneum complicating cardiac surgery — hepatic tear

Aim-background

We report an unusual source of intraoperative bleeding in a patient undergoing cardio surgical reoperation.

Case report

After sternotomy, the haematocrit dropped significantly. This was ascribed to intraoperative bleeding from adhesions. During reperfusion, the abdominal wall was distended with a bluish bulge in the right hemidiaphragm.

Results

Immediate laparotomy revealed bleeding from a tear in the right hepatic lobe without evidence of injury to the diaphragm. The tear was likely caused by blunt trauma from an oscillating saw.

Conclusion

We stress caution when using an oscillating saw on patients with hepatic congestion undergoing a repeat sternotomy. We propose that lifting the sternum in redo procedures might prevent a hepatic tear.     

Left paraduodenal hernia as a rare cause of acute abdomen

Background

Paraduodenal hernias are congenital internal hernias that emerge as a result of the incomplete fusion of the mesentery with the peritoneum and abnormal intestinal rotation during the stages of foetal development. A rare cause of intestinal obstruction, especially in patients with a medical history free of abdominal operations, paraduodenal hernias account for approximately half of the cases of internal hernias and are responsible for 0.2–0.9% of intestinal obstructions.

Case presentation

We hereby report the case of a 39-year-old female patient who presented with a three-hour episode of acute epigastric pain and nausea. Physical examination revealed tenderness and guarding at the palpation of the epigastrium and the left upper quadrant. Computed tomography was suggestive of an internal hernia at the level of the Treitz ligament.

Results

Emergency laparotomy was performed and the incarcerated jejunal loops were restored back to the abdominal cavity, while the defect at the root of the mesentery was suture closed, with care not to include the inferior mesenteric vein. The post-operative period was uneventful.

Conclusion

Though rare, paraduodenal hernias should be included in the differential diagnosis in cases of acute abdomen or upper bowel obstruction, particularly in the absence of previous abdominal surgery. Surgical treatment is similar to that indicated for any other type of hernia, and involves reduction of the hernia’s contents and elimination of the defect.     

Methylene Blue Enteric Mapping for Intraoperative Localization in Obscure Small Bowel Hemorrhage: Report of a New Technique and Literature Review

Background

Small bowel sources of obscure gastrointestinal bleeding present both a diagnostic and therapeutic challenge. Due to the normal external appearance of the vast majority of small bowel lesions that cause obscure gastrointestinal bleeding, multiple methods of intraoperative localization have been reported. When an arteriographic abnormality is found, the use of vital dye enteric mapping is one of the most effective localization techniques.

Case Report

We present a new technique combining superselective mesenteric angiography with methylene blue enteric mapping and small bowel resection performed during the same operative procedure. This technique was successfully applied in a patient with a jejunal arteriovenous malformation. Included is a review of methods of intraoperative localization with a focus on vital dye staining-guided enterectomy.     

Portal Venous Dilatation and Stenting for Bleeding Jejunal Varices: Report of Two Cases

We present two patients who underwent a portal stent placement for bleeding jejunal varices of the afferent loop caused by extrahepatic portal venous stenosis. Case 1 involved a 66-year-old woman who developed bleeding jejunal varices due to extrahepatic portal venous stenosis 1 year after a pancreaticoduodenectomy with intraoperative radiation therapy. Percutaneous transhepatic balloon dilatation and stent placement were performed. Since undergoing the procedure, no bleeding has occurred. Case 2 concerned a 44-year-old woman who had a rupture and bleeding of jejunal varices 16 years after a choledocojejunostomy. Stenosis was observed from the right and left branches of the portal vein to its intrahepatic branches. Both balloon dilatation and stent placement were attempted. However, the stent could not be fully inserted into the intrahepatic portal vein. Portal stent placement is less invasive and radical, and therefore should be attempted for the treatment of extrahepatic portal venous stenosis. However, there are limits to its application if the stenosis extends to the intrahepatic branches of the portal vein. Received: February 8, 2001 / Accepted: July 17, 2001     

A sporadic case of colorectal carcinoma with multiple polyps in a 16-year-old boy: An unusual presentation

Aim and Background

Colorectal carcinoma associated with multiple colonic polyps is rare in children and adolescents without any previous family history of colorectal cancer/hereditary polyposis syndrome.

Case Report

We present the case of adenocarcinoma of the colon and rectum detected by biopsy in a 16-year-old boy with multiple polyps treated at our institution.

Conclusion

Though uncommon, sporadic cases of multiple polyps associated with colorectal carcinoma without any positive family history must always be considered in children with history of a colorectal polyp associated with bleeding. A high degree of suspicion is necessary to detect and treat such cases, thus preventing morbidity and mortality.     

Balloon-occluded retrograde transvenous obliteration is feasible for prolonged portosystemic shunts after living donor liver transplantation

Purposes

The purpose of our study was to evaluate the efficacy of balloon-occluded retrograde transvenous obliteration (B-RTO) in patients after living donor liver transplantation (LDLT).

Methods

Five patients with gastric varices (GVx) and/or liver dysfunction who were treated with B-RTO from January 2001 to December 2007 were enrolled in this study (GVx, n = 2; liver dysfunction, n = 1; both, n = 2). The eradication rate of the GVx, portal vein hemodynamics and improvement of liver function were evaluated.

Results

B-RTO was performed successfully, and the GVx disappeared or decreased markedly in all patients. Recurrence of GVx was not observed during the follow-up. Significantly increased portal vein inflow and improved liver function were observed in all patients.

Conclusions

B-RTO may be an effective treatment for patients after LDLT to prevent bleeding from GVx or to modulate portal vein inflow that is reduced by prolonged large portosystemic shunts.     

The Role of Minimally Invasive Percutaneous Embolisation Technique in the Management of Bleeding Stomal Varices

Introduction

Stomal varices can develop in patients with ostomy in the setting of portal hypertension. Bleeding from the stomal varices is uncommon, but the consequences can be disastrous. Haemorrhage control measures that have been described in the literature include pressure dressings, stomal revision, mucocutaneous disconnection, variceal suture ligation and sclerotherapy. These methods may only serve to temporise the stomal bleeding and have a high risk of recurrent bleed. While transjugular intrahepatic porto-systemic shunting has been advocated as the treatment of choice in patients with underlying liver cirrhosis, histoacryl glue or coil embolisation has been successfully employed in patients who are not suitable candidates for TIPS.

Methods and Results

Direct percutaneous embolisation of the dominant varices was performed successfully under ultrasound and fluoroscopic guidance in two patients using a combination of coils and histoacryl glue.

Results

While transjugular intrahepatic porto-systemic shunting has been advocated as the treatment of choice in patients with underlying liver cirrhosis, histoacryl glue or coil embolisation has been successfully employed in patients who are not suitable candidates for TIPS.

Conclusion

Direct percutaneous embolisation is a safe and effective treatment for stomal varices in selected patients.     

Modified Laparoscopic Splenic Vessel-Preserving Distal Pancreatectomy: Matador Assistance and Peel-Away Technique

Background

Laparoscopic splenic vessel-preserving distal pancreatectomy (lap-SVPDP) is a popular procedure in pancreatic surgery. However, postoperative complications include false aneurysms of the splenic artery, splenic vein stenosis and thrombosis, pancreatic fistulas, abscess, and perigastric varices.

Methods

Eight patients (three men, five women, average age 66.1 years) with benign tumors underwent lap-SVPDP. Lap-SVPDP was performed in the lithotomy position with the head slightly elevated. The splenic vein was peeled longitudinally toward the pancreatic tail. A vessel-sealing system was used to detach the pancreatic body from the greater omentum, and the pancreas was transected using a surgical stapler.

Results

Mean operation time was 254 min; mean blood loss was 163 ml; and mean post-surgical hospitalization time was 13 days. No postoperative bleeding from the preserved splenic vessels occurred, and there were no splenic infarcts or splenic abscesses.

Conclusions

For safe performance of lap-SVPDP, the posterior surface of the pancreas should be completely exposed. The splenic vein should be ‘peeled away’, starting from its central rear, enabling easy detection of its course to avoid inadvertent sealing. With improved operational techniques, lap-SVPDP can be adopted as a standard procedure in pancreatic surgery.     

Arthrolysis of the shoulder in Apert syndrome

Background

Shoulder involvement, with progressive loss of joint mobility, is found in almost all patients with Apert’s syndrome.

Case presentation

This paper reports on a 10-year-old girl with major functional limitation of both shoulders.

Conclusions

Bilateral joint arthrolysis yielded good functional results over a 5-year follow-up.     

Circular Suture Ligation of Presacral Venous Plexus to Control Presacral Venous Bleeding During Rectal Mobilization

Background

Presacral venous bleeding during rectal mobilization is uncommon but potentially life-threatening. Various methods have been proposed for controlling the bleeding, but each has some obvious limitations in clinical practice. We report a simple technique that was designated as circular suture ligation. This technique was efficient in controlling presacral venous bleeding encountered during rectal mobilization.

Methods

The key point of circular suture ligation was to control the bleeding by suture ligating the venous plexus in one or more circles in the area with intact presacral fascia that surrounds the bleeding site while the bleeding site was temporarily controlled with fingertip pressure. From September 2007 to December 2011, 258 patients underwent rectal surgery in our department because of rectal cancer. Uncontrolled presacral venous bleeding with traditional methods was encountered in eight patients (3 %) with estimated blood loss from 300 to 5,000 ml.

Results

Bleeding was successfully controlled in all eight patients with the circular suture ligation. None of the patients required reoperation for bleeding or other issues. No patients developed chronic pelvic pain after the operation.

Conclusions

Our experience suggests that circular suture ligation of venous plexus in the area with intact presacral fascia that surrounds the bleeding site is an effective and simple technique to control presacral venous bleeding when traditional techniques fail.     

Extended Right Hepatectomy in a Liver with a Non-bifurcating Portal Vein: the Hanging Maneuver Protects the Portal System in the Presence of Anomalies

Introduction

Variations in portal vein anatomy occur in 20–35 % of individuals. A non-bifurcating portal vein (PV) was suspected on preoperative imaging in a patient with a large right lobe hepatocellular carcinoma. The single PV curved within the liver parenchyma from right to left supplying second-order branches along its course.

Case Report

Utilizing the hanging maneuver, an extended right hemihepatectomy was safely performed. This approach allowed for preservation of the main PV and its left-sided branches while easily identifying the second-order right branches for ligation.

Conclusion

Knowledge of portal vein variations and identification preoperatively by cross-sectional imaging are critical. The hanging maneuver aids in the preservation of the main portal vein and its left-sided branches during right hemihepatectomy in the presence of portal vein anomalies, and this technique can be used to improve safety in hepatobiliary surgery.     

Ectopic Bone in the Abdominal Cavity: A Surgical Nightmare

Introduction

Heterotopic mesenteric ossification (HMO) is a rare clinical entity with less than 40 reported cases in the literature. Frequently associated with prior abdominal surgery or trauma, the precise etiology and optimal approach to its management remain undefined.

Case Report

The index patient is a 58-year-old male who originally presented with perforated diverticulitis. Following resection, the patient developed an enterocutaneous fistula. After a trial of conservative management, the patient underwent exploration and was found to have widespread intra-abdominal calcification. Sheets of calcific tissue were resected, and a diagnosis of HMO was confirmed via pathology. The patient had a postoperative course complicated by bleeding and redevelopment of enteric fistula. Following a prolonged hospital course requiring multiple operations, the fistula persists, and the patient remains on parenteral nutrition.

Discussion

The etiology of HMO is unknown. Diagnosis requires a high degree of clinical suspicion, as radiologic findings are often misleading. A review of 18 cases demonstrates significant morbidity associated with operative intervention. Nonsteroidals, in particular indomethacin, have been shown to decrease heterotopic ossification, but their role in mesenteric disease is not clearly defined.

Conclusion

HMO is a rare but complicated pathologic process. A trial of conservative management with NSAIDs, bowel rest, and total parenteral nutrition is prudent, given the high rate of morbidity and mortality associated with operative intervention.     

A challenging hernia: primary venous aneurysm of the proximal saphenous vein

Introduction

Primary venous aneurysm is a rare, but essential consideration in the differential diagnosis of an inguinal and femoral hernia.

Methods

We report a case of a 43-year-old man who was referred for evaluation and treatment of a femoral hernia.

Results

The patient presented with a 3-month history of an asymptomatic tumor on his right upper inner thigh. Physical examination noted a non-tender, non-indurated tumor.

Conclusion

Surgical exploration demonstrated a primary venous aneurysm of the proximal saphenous vein.     

Pylorus- and spleen-preserving total pancreatoduodenectomy with resection of both whole splenic vessels: feasibility and laparoscopic application to intraductal papillary mucin-producing tumors of the pancreas

Background

Total pancreatectomy is recommended for intraductal papillary mucinous tumors with widespread involvement of the entire pancreas. Organ-preserving and minimally invasive surgery should be applied in benign and borderline pancreatic lesions.

Methods

Pylorus- and spleen-preserving total pancreatoduodenectomy (PpSpTPD) with segmental resection of both splenic vessels was attempted for five patients. The technique was based on the concepts of two surgical procedures: pylorus-preserving pancreatoduodenectomy and distal pancreatectomy with segmental resection of splenic vessels (“extended” Warshaw’s procedure).

Results

Three patients underwent laparoscopic-assisted PpSpTPD and two underwent open surgery. No mortality was noted. Short-term follow-up (median, 28?months) suggested that all patients tolerated the insulin therapy and showed relatively good nutritional status. Only minimal to moderate perigastric fundal varices were noted without gastrointestinal bleeding.

Conclusions

PpSpTPD with segmental resection of both splenic vessels is feasible and safe. Even a minimally invasive approach can be indicated in selected patients.     

Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy

Introduction

Portal and mesenteric vein thrombosis are relatively uncommon surgical complications, with difficult diagnosis and potentially severe consequences due to higher risk of bowel infarction. The purpose of this study was to present a series of patients who developed postoperative portal vein thrombosis after laparoscopic sleeve gastrectomy.

Methods

This is a retrospective analysis of patients who underwent sleeve gastrectomy between June 2005 and June 2011 who developed portal vein thrombosis. Demographic data, personal risk factors, family history of thrombosis, and postoperative results of thrombophilia study were analyzed in this study.

Results

A total of 1,713 laparoscopic sleeve gastrectomies were performed. Seventeen patients (1 %) developed portal vein thrombosis after surgery. Of the 17 patients, 16 were women, 8 had a history of smoking, 7 used oral contraceptives, and 2 had a family history of deep vein thrombosis of the lower limbs. All patients were discharged on the third day of surgery with no immediate complications. Symptoms presented at a median of 15 (range, 8–43) days after surgery with abdominal pain in most cases. One case required emergency laparotomy and splenectomy because of an active bleeding hematoma with massive portomesenteric vein thrombosis. In 11 cases, a thrombosis of the main portal vein was identified, in 15 the right portal branch was compromised, and in 10 the left portal branch. Eleven patients presented thrombosis of the superior mesenteric vein, and ten patients presented a concomitant thrombosis of the splenic vein. A massive PMVT was presented in six cases. Seven patients had a positive thrombophilia study.

Conclusions

Portal vein thrombosis and/or mesenteric thrombosis are relatively uncommon complications in patients undergoing bariatric surgery. In this series, the portomesenteric vein thrombosis was the most common complication after LSG in a high-volume center.